“I seem, then, in just this little thing to be wiser than this man at any rate, that what I do not know I do not think I know either..”
Socrates

Apology by Plato

The events of the last week will undoubtedly shape the future of Britain in a monumental fashion. First, an election like none we have seen for fifty years. Called in hubris, led to nemesis, won, in truth, by no one. History-making nonetheless. The prevailing wind of politics has changed, now blowing Left of centre for the first time in nearly a decade. Corbyn has an approval rating of +6, Theresa May a disapproval rating of -34, nearly mirror opposites of where they stood in November. Who knew?

Theresa May and the Conservatives struck a conciliatory tone. “Austerity is over” they said, in radio interviews, in leaked excerpts from backbencher committee meetings. The “mood has changed” they said.

As details drip out of what will undoubtedly be known as the biggest domestic disaster since Hillsborough, a hazy but consistent picture coalesces. The fire began reportedly in a fourth floor flat, starting with a fridge. The residents had campaigned for years before about power surges in the building, about the risk of a lethal fire with appliances, but sadly, were ignored. Within minutes, it is reported, the fire had spread out of a window and roared up the side of the tower, consuming the external cladding system as one resident described “like matchsticks”. This external cladding had been part of a recent £8.7 million refurbishment, subcontracted by the private enterprise managing the tower, KCTMO, to update the insulation and aesthetic aspects of the outer structure. In the Times today, it is reported that the cladding material used is illegal in structures greater than 18 metres, is flammable when an alternative fire resistant material would’ve cost just £5000 more, and is illegal in Germany and the USA. Sky News’ Faisal Islam shared a BRE presentation this weekend, a diagram of exactly the kind of disaster that befell Grenfell, dated June 2014, three years ago exactly. In summary, we await the public inquiry that must happen, but it seems 58 (at time of writing) people died in a preventable disaster, that was forewarned, already forestalled in other countries, and seems to have been the result of thoughtless (one hopes) cost cutting from a private company.
But, as Damian Green stated in an extraordinary Radio 4 interview, “we must await the experts”.

Which struck a chord with me.

The mantra “prevention is better than cure” is as true in medicine as it is in fire fighting. Much of what we do, day to day, is about preventing future disease, rather than treating it’s corollaries. We use safety cannulas for preventing needlestick injury, we campaign to stop smoking to prevent lung and other cancers, we screen and treat alcoholics on admission to hospital to prevent deadly withdrawal seizures. When we see impending disaster threatening human life, we have a duty to act, as best we can.

A disaster likely already happened in the NHS, and I cannot help but see the parallels with Grenfell. In February of this year a Royal Society of Medicine Report looked into what was explained away by the government as a “statistical blip.”. Since 2010 the death rate in the U.K. was rising, for the first time in fifty years. More people were dying. To be exact, 30,000 “extra” people died in 2015 compared to what was expected. This study attempted to explain where these extra deaths came from. Was it a subpar flu vaccine one season , as Jeremy Hunt, once and current Health secretary, had claimed? No, the study concluded, the only explanation that fit the data was that 30,000 excess deaths were most likely a direct result of cuts to health and social care services.

Let that sink in.

30,000 men and women, potentially your grandmother or father, sister or uncle, whose deaths were in some way contributed to by cuts to services in the name of “austerity”. Like Grenfell, cutting corners and saving pennies, led to a national disaster. Like Grenfell, multiple agencies have limited oversight over the system as a whole. Yes, the buck stops with the government, but I’m sure they can pass it through any number of government and non-government subsidiaries. Like Grenfell, this essential public service, is sub-contracted in places to private companies, beholden to shareholders as much, if not more, than to the public they are supposed to serve. And like Grenfell, warnings about impending disaster, from “experts” and public alike, have fallen on deaf ears. But unlike Grenfell no one saw these deaths for what they were, a national disaster on a behemoth scale.

If you think I’m politicising this tragedy, you have it backwards. The politics came first, then the tragedy.

Which brings me back to where we started. “Austerity is over” they said. The “mood has changed” they said. As if austerity were always a fanciful choice, a frivolity that was chosen on a whim, as one might decide on a suitable tie, or a wallpaper for the living room. I don’t remember anyone claiming austerity was a “mood” when Osbourne and Cameron were laying waste to health and social care budgets, schools and police funding. Austerity was essential, they said. We have to “live within our means” they said. Except some of us didn’t manage to. Potentially as many as 30,000 of us, our most vulnerable.

So now austerity is over. Was it ever actually necessary? The short answer is no. The long answer is, perhaps for a while, but ultimately still no. Despite what the Mail and Sun has peddled for half a decade, the idea the economy is akin to a household budget is laughable. Pretending we only have control of spending in a government trying to “balance the books” is patently stupid; a government sets it’s own revenues, through tax and VAT, NI and council tax, levies and custom duties, subsidies from other countries, like the EU. Austerity was harmful to our economic recovery. This isn’t left wing socialist claptrap, this is mainstream economics. The IMF agrees as did a large backing of the UK’s top economists. This is economic theory that goes back a hundred years. Any economist could’ve told you that. But of course, we had had enough of listening to “experts” then.

Apparently that’s all changed now.

If we are listening to architects and fire officers again, perhaps we could list to economists and health experts again too, to teachers and police federations. To paraphrase Socrates, wisdom is knowing what one does not know. As a doctor I’ve begun to understand this more and more. Being conscious of the limits of my knowledge makes me safer, means I can operate with uncertainty and know where I need a colleague’s advice, or my boss.

In the age of the internet it seems we now know everything, but understand nothing. For too long we all “knew” that austerity was necessary, that “too much red tape” was throttling business and enterprise, that the NHS was “bloated” and spending “too much money”. Did any of us examine where this “knowledge” came from?

Now we see we knew nothing at all. I hope from these tragedies we can salvage some wisdom.

In an impassioned interview, the MP David Lammy spoke about the “safety net” of schools and hospitals, of decent housing, that is falling apart all around us. Austerity has shredded that safety net, and many have died slipping through the gaps.

Austerity is over, they say. I think we can rebuild this safety net, I hope we can fix the NHS.

2nd January 2017
New year, new diary! Just moved to our forever-family home. Nice area, good primary just round the corner for Charlie and we are only twenty minutes from Dave’s work. Only issue is they just ‘downgraded’ our local A&E– but I’m not worried, although Dave thinks I’m a hypochondriac! GP is local and there’s a big hospital a short drive away. Anyway, back to unpacking!

3rd March 2017
Finally got round to signing us all up at the GP- it’s such a faff. They wanted to see all our passports, and could only sign us up between 1-2pm on Wednesday. Who can manage that? Charlie had a cough for a few weeks so that finally pushed us to join. Waiting time bit long though- two weeks! Oh well. He’s fine.

10th April 2017
Still haven’t got an appointment for the GP! Charlie is looking a bit peaky- it’s been too long now. Phoned up for emergency appointments but the GP never has a free slot. I heard from Linda next door they might have to close- can’t maintain the practice on the funding they’ve got. Never mind. Plenty of other NHS GPs around. Even had a leaflet for a private GP through the door today- £40 an appointment. Bit steep. But booked one anyway. Dave didn’t mind.

17th April 2017
The private GP seemed very nice- referred Charlie for lots of tests though. Dave is worried- he thinks it’s a scam. I don’t. I saw the GPs face- he thinks Charlie is really sick. He asked us if we wanted to stay with the NHS- is that really a thing now? I don’t think we can afford any more private tests. He’s sending us to our local NHS children’s department.

24th May 2017
Waiting for an appointment is agonising. Lost our nerve tonight when Dave thought Charlie coughed up some blood. Everyone was a bit flustered so we went to local children’s A&E- except it was closed. Lack of staff. What the hell does that mean? I’ve never heard of a hospital being ‘closed’. What do we pay our taxes for if not the NHS? We got redirected to another hospital, had a minor divorce-level fight outside the A&E and then decided just to take Charlie home. Our appointment is next week anyway.

1st June 2017
Charlie has cystic fibrosis. I’ve spent hundreds of hours looking all over the Internet and everywhere about it. The specialist at the hospital was very nice- but we were still all in tears. We have another appointment next week. It’s still settling in- my child will always be unwell. I don’t know how to handle this. We tried to see the NHS GP this week- just to touch base. They’ve closed for good. I went back to the private GP for an appointment- looked a lot busier. Had to wait a few days this time. Saw a different GP for £50 this time. Wasn’t very helpful. What a waste of money.

10th Oct 2017
Charlie is managing on his inhalers and things. The NHS department at hospital is great- we have the mobile of Sandra, the nurse specialist for Charlie and any problems just call her up. Heard some mutterings about closing the hospital, ‘centralising’ services. Sounds like a good idea, but Sandra reckons many services like theirs will be cut in the reshuffle. Off the record she said the hospital might close entirely. I left pretty frightened, imagining losing such a lifeline for us. Wrote to my MP when I got back. Why are all the NHS services shutting down?

2nd Dec 2017
Sandra called- they are being moved to another hospital, and their service halved. More ‘efficiency savings‘. She’s not covering anymore- it’ll be a duty nurse system now. I did the maths- our local specialist children’s hospital is now forty miles away. Just shy of 45 minutes by car. What we will do in an emergency? Dave is starting to get chest pains when he’s carrying Charlie up the stairs. We can’t afford to go back to the local private GP right now, the next closest NHS GP isn’t accepting new patients. Just ignoring it now, and hoping.

5th Jan 2018
More leaflets through the door- private health insurance companies offering discounts. Our local NHS hospital has just been taken over by a private firm. Me and Dave had a huge row, and then decided to look into private health insurance. We both believed in the NHS, but it’s clear that it’s not going to survive unless the government step in. Plus Dave is self-employed and so am I- might be a bit trickier. We will struggle through.

20th March 2018
Got insured with Health Co. – few others in the street did the same. Quite steep for me and Dave – lots of cancer stuff on both sides of our family, plus we both run our own businesses. Dave went to an appointment on the very next day- Health Co. GP sent him straight to the heart doctor at the private hospital. Long story short- Dave needs a stent in his heart- not a heart attack, but pretty close according to the doctors. Thank god we got the insurance when we did. Charlie has been good.

1st April 2018
Dave had his heart op today- says he’s feeling much better. Stayed in a nice room in the Health Co. ward- had to pay an excess though, £500. A lot more than we could afford. Really weird feeling as a 1970s child having to worry about money and healthcare in the UK. Anyway- no worries. Everyone’s at home and everyone’s well.

9th April 2018
Health Co. sent us a huge bill today. They say Dave isn’t covered for his op, because he had pre-existing symptoms. Altogether they want nearly £9,000. We were aghast. We tried contacting the NHS hospital to see if they would cover us – we still pay taxes. An hour of ringing got me to a stressed sounding secretary who just laughed in my face. We tried to move back to cardiology at our local NHS hospital- but they don’t do outpatients anymore. Have to raid the savings, probably add a bit to the mortgage too. Need to get the hang of this insurance business better.

15th June 2018
Charlie is sick again – looks like his cystic fibrosis. Went to a great Health Co. GP who wanted to send us to the Health Co. hospital. The hospital wanted to know is Charlie insured. We thought he was- – the hospital says not. An hour of furious tears on the phone turns out they are right- he was excluded because of his cystic fibrosis from a regular family policy. We could pay out of pocket, but the nice Health Co. GP said that might costs hundreds of thousands of pounds. We’d have to sell our house. So I called Sandra- she told us to drive to her NHS hospital, even though it’s an hour and half away. I never expected to be choosing between money or my family’s health. How did this happen? Anyway, we drove to the ‘central’ children’s hospital – and they rushed Charlie to their high-dependency bay. He’s stable now. Dave and I can’t seem to talk to each other, every conversation turns into blaming the other for the insurance rubbish. Bad night for everyone.

17th June 2018
The NHS has really changed- much of the hospital is actually just private companies that have taken over different sections. I’m signing all sorts of documents about insurance and waivers and declining ‘optional’ extras. Whole wards of the NHS buildings are empty. It’s scary. The NHS staff haven’t changed though- Charlie’s paediatric team are the same amazing, hard-working angels they’ve always been. Sandra has been in every day- she looks awful. I’ve never seen her so stressed. I caught her for five minutes to catch up and thank her- I asked her how’s work- and she started crying. Most of her colleagues have left the NHS side, she’s the last cystic fibrosis nurse left in the county for the ‘uninsured’. She gets heartbreaking phone calls like mine every five minutes. She has to turn many of them down. She can’t cope. Every month they get less funding and are told to be more ‘efficient’. She’s close to retirement she told me, so she said she was determined “to see it out”. Her career? I asked. No, she said, “the NHS”.

21st Aug 2018
Charlie is back at home. We did two months driving an hour and a half a day to be with him. We took it in shifts, so Dave and I haven’t really been in the same room for more than twenty minutes for 8 weeks. Our relationship is struggling, but at least Charlie is better. I managed to get him back on a Health Co. policy- but the costs are phenomenal. We had thought about a second baby, and if my business had done better maybe even a third. Now we will settle for Charlie. Health Co. gave us a card to show private ambulances to get to our local hospital. Our GP is private, all of Dave’s cardiology appointments are now private, at huge cost, but at least we are covered.

10th Jan 2019
Dave’s mum had a stroke. She’s 92 and the first we heard about it was a call from a care home telling us she can’t pay. We were shocked. She’d been sent to a ‘central‘ elderly care ward fifty miles away, and then sent back to a care home near Dave’s brother. Obviously Dave’s mum was still on the NHS. Apparently there is supposed to be free coverage for the elderly, but it doesn’t cover care costs. We went to the care home- it seemed nice enough. It’s all private though- the manager was a lovely man, who explained we basically had two options; sell Dave’s mum’s house, the house he grew up in, or move her to the NHS subsidised home a few towns away. We went to the NHS one- bit shocked by how run down it looked. Social care apparently has been cut just as hard as the NHS was– it’s all basically private now unless you can’t afford it. We are selling Dave’s mums house.

3rd May 2019
I found a breast lump today, in the shower. It felt like a hard rubbery knot, just under my right breast. Scared and anxious the first thing I did, still in my towel, was go to the Health Co. policy documents in my office. I read them three times over- trying not to linger on the ‘C’ word, but also making damn sure that if I go to the doctor now, we won’t lose our house. Only when I was sure did I go tell Dave. I felt sick watching his face as he felt it too. We booked into a private GP appointment- have to wait a week now, and still have to pay £60 excess.

30th May 2019
Had all our scans, tests, appointments, re-appointments. It’s a low grade breast cancer. Hasn’t spread- it’s an operation, then chemotherapy for a few years, then done. Sort of relieved, sort of mind-bogglingly terrified. All private staff, all the way through. Dave and Charlie have been very supportive. Hasn’t cost too much in excess payments etc. No holiday this year but let’s get some perspective. Op will be next week.

12th June 2019
Op went well, back at home on tablet chemotherapy. The doctor offered me radiotherapy as well- I thought that was a good idea. Booked in next week.

3rd August 2019
A bill arrived today. Another bill. I can’t cope with this. It’s for some aspects of my cancer treatment- apparently the company made an ‘error’, a lot of treatment was ‘extra-contractual’, bottom line; they won’t pay for it now. The CT scan that gave me the all-clear was ‘extra’, the radiotherapy treatment was ‘extra’, all of the nights in hospital with side effects were ‘extra’. The ‘extra’ cost is £192,000.
I keep looking at that number, wondering how it ever came to this.
My mum had cancer- she had a thyroid lump ten years ago. I went to all her appointments, in and out of NHS hospitals, specialists, scans, surgeons. She’s fine. And she never once paid a penny more than her taxes. What a different world we live in now.

5th November 2019
If I sell my stake in my accounting firm, Dave sells his business and goes back as an employee, and we sell our house and downsize we can just about make the payments without declaring bankruptcy. Charlie’s insurance is gonna hit us hard though.
I saw Sandra in the paper today- I spotted her face protesting in a crowd outside her NHS hospital. Shut down, no funds and not enough staff they say. I text her. She’s retiring now. She’s seen it out, and for her the NHS is over.
For the rest of us as well it seems.

3rd Jan 2020
I did some research. We were all told private companies came to ‘save’ the NHS, that healthcare was no longer ‘affordable’.
But compared to our neighbours the NHS didn’t cost very much- just under 8% of GDP in 2015, well below what Germany and France were spending. We were told that more money was being given to the NHS, but it never really was. Compared with demand the last ever decade of the NHS was also it’s most austere.
Now we can just get by without the NHS- but only just, and we were fairly well off. I worry for those that aren’t. Every day I worry about the next treatment for Charlie or what if my cancer comes back? How will we afford the co-payments and excess charges?
Now the NHS is still around, but it’s gone in all but name. It’s for emergencies and the unemployed and poor only. Basic healthcare. I don’t pay any less tax- more money goes on my family’s hospital bills than ever before.

1st July 2020
A new government is about to be elected. I’m going to campaign hard for the NHS to return. Too many of us are suffering its loss. But no mainstream party has a realistic plan to restore it. It’s simply too late.

We’ve had some rough times in our profession. Sometimes it feels like we work in a building that’s being demolished, and Hunt and friends are wearing ear-protectors and smiling, oblivious to our screams.
The frustration seeps in, and bubbles up between us if we let it-but the one thing that got the junior doctors dispute going, kept it going and pushes it still, is unity.

98% of doctors voted for industrial action. We had a forum of 68,000 doctors able to each have a voice. These are amazing levels of cohesion. The yes/no vote on the contract became bitter- that screaming frustration came through the cracks as we pulled in opposite directions.

Which is of course exactly what our true adversary, Jeremy Hunt and co, wanted.

I felt a surge of hope again this week. The emergency campaign to raise funds for justiceforhealth against imposition hit £120,000 in just 48 hours. We remain united. We fight on.

I want to apply this model to Labour.

Full disclosure- I’ve voted all over for many years: Lib Dem, then Labour, then Corbyn.

Now no one will disagree Labour is in a mess. Neither will any Labour supporter disagree the Tories are rampaging across the country and tearing up the welfare state. My red line issue is the NHS and the Tories are well on the way to forcing total collapse.

The back and forth between Corbynistas and Blairites/Eagle-Eyes/Smithies has been childish, moronic, insulting and divisive. On both sides.

I think no one can disagree Corbyn has failed as a leader. His PR is rubbish- yes you can blame the media, which has been more biased against him than any political figure in recent years, but that just means he needed to work harder. Dropping press releases at the wrong time, allowing damaging behaviours by supporters to become dominant narratives, easy gaff after easy gaff for tabloids to run.

Contrast that with Boris Johnson’s PR team that plastered over exit signs at his Brexit resignation speech JUST SO THERE WASN’T A PHOTO OF BORIS AND AN EXIT SIGN. That’s PR we need in spades.

But you also cannot argue that the wider Labour Party has also failed. Failed to capitalise on the huge influx of support and interest in Labour with Corbyn. Failed to create a cohesive opposition in followership- every labour MP voting against the leader made more headlines than the vote itself. The image of a fractured useless opposition is going to lose more votes than Corbyn ever would.

But whatever your opinion the lesson I want to impart to you, Labour, left, middle or other, is one of unity. Watch the television interviews of junior doctors arguing over strikes, or the debate on channel 4 after the yes/no contract vote. I give you examples of how a group can fundamentally disagree and still work to a common purpose. We still treated each other with respect and civility.

In Labour, we can still agree that the Tories will ruin this country and destroy the NHS. We can still agree that whoever the leader the opposition needs as tight a team as the government.

If Corbyn stays, will the anti-Corbyn crowd stay and work with him? Unity is the only way we will win, returning to the backbenches to continue sniping will only serve the Tories.

If Smith wins, will Corbynistas stay on, and support the party that just destroyed their dream? Yes, you must. Because ultimately the party should be bigger than all of us, and if you want to change it you have to stay.

Please remember we are literally squabbling over deck chairs on the Titanic, while iceberg Tory rips the country asunder.

Working together brought out the best in us as doctors. In Labour we have to do the same. Or we will lose everything.
Juniordoctorblog.com

So May is in, Hunt stays, Brexit means Brexit. It’s all change in a crazy week of politics. But what hasn’t changed is the NHS is still about to collapse. May will likely be the last Prime Minister to oversee its demise.

It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.

In this part we will simply explain why the cost of modern healthcare rises every year just to stand still, which is fundamental to understanding the funding needs of the NHS.
This is difficult, but I think best explained if you simplify the entire health system as treating a single person, let’s call her Beverley.

Beverley is born in 1948- her birth is at home, with no healthcare professional, midwife or monitoring. Several of Beverley’s siblings are also born this way- unfortunately two die before they are one. Sadly an uncle has a heart attack at 52 and passes away.

Beverley grows up, and fortunately remains healthy. She marries, Bob, and she has her kids in 1968. She has every one in a hospital, with a midwife. One requires surgery. Beverley’s own mother has a stroke and dies at 63. Bob decides to stop smoking.

Beverley gets older. Her first grandchild is born in 1988, in hospital with electronic monitoring and emergency caesarean. Beverley’s second grandchild is born at 25 weeks, and spends three months in the new intensive care baby unit. Stressed grandparent Bob has a heart attack- he is rushed into hospital and has an emergency procedure to open the blood vessels in his heart. He is at home in time to hold his new granddaughter for the first time.

Beverley and Bob stride on, both retiring at 65. On their 50th wedding anniversary Beverley feels odd, can’t find the words to toast, and can’t raise her left arm. Her daughter dials 999- Beverley has a stroke, just like her mother. Fortunately she gets to hospital and 30 minutes later she has had a brain scan and a clot buster is being infused into her arm. She makes a full recovery, and goes back home a day later.

The junior doctor looking after Beverley spots a shadow on the routine chest X-ray she has. She is diagnosed with lung cancer.

Bob is going spare. They meet the specialist, the cancer is treatable and they start right away, six rounds of radiotherapy then weekly chemotherapy. It’s hard, and Beverley goes into hospital twice with complications.

Halfway through Bob has lots of abdominal pain and throws up some blood. Rushed to hospital he has an emergency camera test into his stomach – he’s developed a stress ulcer, which they clip and repair. He’s in hospital for a few days. Gratefully Bob and Beverley return home.

Beverley goes into remission, but is very frail now and is falling a lot at home. Now in their 80s, Bob gets chest pain trying to look after them both, and Bob needs three more stents put in to open blocked heart vessels. Bob and Beverley ask for some social services support at home- a carer comes once a day.

Overnight one night, Bob passes away in his sleep. Beverley is distraught, but at the funeral she asks her daughter; “Where’s Bob?”. Concerned, her daughter takes her to the GP. It’s clear Beverley now has dementia. She is moved first to a sheltered flat, then a residential home, then a nursing home.

She dies in hospital of a severe pneumonia at 83.

This isn’t a sad story- this is modern life and modern healthcare.
Why did i tell you this story? To show you how healthcare has changed. Let’s look at some facts.
In 1948 the average female life expectancy was 71. In 2016 it’s 81.5.

Beverley’s mum died at 63, while Beverley lived into her 80s. People are living longer.

But also diseases that were previously fatal are now treatable. Mortality for conditions such as coronary artery disease have halved in fifty years- Beverley’s uncle died of a heart attack, but Bob survived two. Stroke survival and stomach bleeds are now readily survivable where fifty years ago they were not.

But these treatments are very expensive- the technology to open blood clots through vessels is super high tech and costs £3000 a go, advanced chemotherapy and radiotherapy treatment costs can run to hundreds of thousands per person, and intensive baby care costs £12,000 a week.

In short- we can do more every year, so we do. And those that we save live on as survivors- but this comes at a cost.

The cost of healthcare per year for an 85 year old is around 4x that of an under 65. The proportion of the population over 65 will rise to 25% by 2040. And alongside that the population is growing, by around 30% since the start of the NHS- so there are 30% more Beverley’s and Bobs than we started with.

So more people, who need more treatment, are treated with more medicines and survive more to need more treatment in the future. And let’s not forget they will need more social care.

This is why the NHS needs 3-4% more funding every year.

That seems like a lot- it’s a tremendous challenge. But we aren’t rising to it as our neighbours are. Of the G7 countries we currently spend the 2nd least on healthcare, well behind the US, Canada, Germany and France.

With the current healthcare budget under the Tories, we will be spending just 6.7% GDP by 2020- lower than Lithuiania and Hungary.

Despite that the NHS is still consistently ranked as one of the best healthcare systems in the world. In 2012 the US commonwealth fund found it the most efficient, safe and accessible system out of all countries ranked, and also spent nearly the least.
Whew.

So now you now that the NHS needs a rising budget to meet rising demand, like every other modern country. Yet we aren’t funding it anywhere near that level, and we aren’t meeting that demand.
In short, the NHS is about to collapse.
Find out how in;